Provider Demographics
NPI:1063866564
Name:ROSE, LAURA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3401
Mailing Address - Country:US
Mailing Address - Phone:267-312-1630
Mailing Address - Fax:
Practice Address - Street 1:2510 MARYLAND RD
Practice Address - Street 2:SUITE 250
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1109
Practice Address - Country:US
Practice Address - Phone:267-481-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL005312L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist